The abolition of Public Health England (PHE) announced last week could substantially affect drug and alcohol services - how they are commissioned, how they are experienced by the people who use them, how we will monitor their success and how we will support and incentivise good practice.
Up until 2012 Drug treatment was classed as an NHS service. People had a right to receive it and a right to expect it to be of a certain quality. Drug treatment was procured within a separate framework either directly by a Drug Action Team (DAT) or the Primary Care Trust (PCT) commissioning team for the DAT. The Health and Social Care Act 2012 changed all that. Since 2012 the responsibility for developing and commissioning drug treatment has been that of the Director of Public Health (DPH) within local authorities. There is no obligation on Local Authorities to commission any drug services if they don't want to.
The old National Treatment Agency (NTA) was rolled into the newly created PHE. Since then it has been their job to advise local areas what services they might need and how they might want to commission them. The PHE function has also been to support the implementation of the public health aspects of the government’s drugs strategy. PHE are responsible for monitoring delivery, which they do against the Public Health Outcome Framework.
The consensus - as far as there is one currently - seems to be that the bulk of PHE functions that do not directly relate to managing health threats will transfer either to local Directors of Public Health (DPHs) or back into the Department for Health and Social Care (DHSC). But against that there are challenges related to the perilous state of local government finances; the integration agenda for NHS England; and the reluctance centrally to create any new national body.
This is important stuff and broadly speaking it could go in one of two directions in which drugs will either get shoved back in its corner, with the effectiveness or indeed existence of drug treatment largely a matter for the local DPH, or we could start to resolve some of the challenges which have been inherent in our system for the last decade by redesigning how we manage drug treatment.
Normally, being of pessimistic bent I would expect the former, but there are other factors which must be considered before we consign ourselves once again to second class health issue status.
The first is the Independent Review of Drugs undertaken by Dame Carol Black last year, part one of which reported just before lockdown. The review was established largely as a response to the rising drug related death rate and concerns about the sustainability quality and penetration of our current approach (including treatment). One of the findings of the review was that the shift of the commissioning function from DHSC and the DAT to the DPH's, presented some difficulties. They observed significant regional variation in spending and also variation in the skills and abilities of commissioning teams.
"Because treatment is commissioned separately from other healthcare and is outside of the NHS, it is much harder to control the quality of care and clinical safety. Providers compete for commissions on price and, increasingly, a small number of third sector providers have dominated the market, offering basic services with no incentives to enhance quality" Independent Review of Drugs Phase One Report
Dame Carol's team have just closed their call for evidence for the second part of the review. Among the questions they asked were a number relating to structures that would support a better coordinated approach to the provision of drug treatment.
This is real meaty stuff. We are being asked to imagine different ways of working to incentivise improvement, ensure safety and increase the penetration of drug treatment into the community of people with drug problems. While agreeing that dwindling resources for treatment are problematic, she identifies the operation of the market (with a small number of dominant providers) the skills of all - including commissioners - and the integration of treatment with other local helping services and with the criminal justice system as areas in which we could improve.
This brings me to the second aspect of the management and commissioning of treatment which I think we should consider. It’s one we have never been very good at thinking about. We need to consider our position as a sector alongside the shift to local health and care integration. In 2019 The NHS Long Term Plan (LTP) made clear the direction of travel that had been apparent for most of the last decade and certainly since the establishment of the 42 Sustainability and Transformation Partnerships (STPs) in 2016. It said:
"Local NHS organisations will increasingly focus on population health – moving to Integrated Care Systems everywhere"
Fine words. We have known for a long time that integration was the next necessary shift for health and associated services. The proof of the pudding is as ever in what happens outside strategies and plans, but it’s safe to say that across England every local health care system is undergoing significant change right now.
The LTP describes an ICS like this:
"An ICS brings together local organisations to redesign care and improve population health, creating shared leadership and action. They are a pragmatic and practical way of delivering the ‘triple integration’ of primary and specialist care, physical and mental health services, and health with social care"
Some areas have gone hell for leather into the establishment of an Integrated Care System. As "vanguards" they have established new systems of care that bring together the range of agencies who provide health and some social care services under a single contract with each provider having a responsibility to every other provider to ensure they work together in a person-centred way. Other areas have literally put in place one big contract with one big provider who may or may not subcontract aspects of it to other people. In other areas elements of the system have been better integrated.
For example, the National Association of Primary Care (NAPC) has developed the Primary Care Home Approach (PCH) . In PCH the health (all of primary and some secondary) and social care professionals work together within one system covering a small number of practices with a population weight of up to 50k people. They have an integrated workforce, they prioritise personalised individual care, they are subject to a single performance regime, and they work with a defined registered population.
Thus far I have seen one area in which drug and alcohol services have been part of this integration in any real way. I am sure there will be more, but not many more. In most area drugs and alcohol services are commissioned outside the integrated system and I have been told many DPH’s involvement in the developments of ICSs has been extremely limited. There are dangers in integrated systems for drug and alcohol treatment - the lack of specialism may dilute what expertise we have left on the ground and delivery may become manualised and mediocre, lacking personalisation. On the other, so many of the problems our clients deal with are the business of other agencies - eg housing and welfare benefits. We could really enhance the care of people with through better integration with the other services that should be helping.
So, what does happen next?
Should Drug and Alcohol Treatment funding stay with DPHs? Should the total responsibility for commissioning - and the choice about whether to do it or not remain at a local level?
Should we return drug and alcohol treatment to be an NHS commissioned service - and provide those seeking help with protection from shoddy or non-existent services under the NHS constitution?
Or should we recreate a strong focussed central agency that not only provides expert advice but also makes people follow it, effectively commissioning services locally to a centrally devised template?
Should commissioning happen within the new Integrated Care Systems and, if so, will drugs and alcohol be lost inside massive multi -agency contracts ?
Should primary care take on a larger role in treatment, with specialist services only for those with complex needs?
How will Dame Carols Black’s desire for a regenerated and revitalised new approach to commissioning be made a reality? How do we rebuild our workforce that has been so badly damaged by ten years of letting the market take charge?
Finally, how should the research and advisory role developed within PHE to support commissioners, service users and providers alike in developing and disseminating effective evidence-based approaches be continued? It is important and it’s something we must preserve. We have recent and not so recent examples of how this can work well or not so well, going back to the old non statutory agencies - SCODA and ISDD (which became DrugScope), Substance Misuse Advisory Service (SMAS) - which as part of DH developed Models of Care - , the NTA and PHE itself.
We have seen that having all of the evidence but none of the levers of power - like ISDD or DrugScope means we get some brilliant innovation but with no real incentive for anyone to follow it. But when we develop central agencies with strong leadership, we run the risk of standardising practice, but stifling innovation creating cheap risk averse services and a market top heavy with large providers.
As ever when I write these pieces I send them to a number of people to review. The comments I got back from folk with this one really surprised me. While there was broad agreement that things would indeed change, there was a real fatalism about the ability of people in the field - no matter how senior or well informed to change them. The sense that money was draining away from drug treatment and indeed all of public health is well founded. The relative weakness of PHE in lobbying for increased priority has been noted by many commentators across health. It strikes me that in making the decision to abolish PHE the government has landed itself with a series of problems to which they need solutions. And in the case of drugs and alcohol, they don't have one.
Whatever solution we favour, it is one we should not leave to chance. Over the next few months it’s our responsibility as interested parties to talk about the potential future, to play out the different models and seek to influence decision makers. the danger is that if we do not engage, that a solution will be found that compounds the problems of the status quo.
Practically the only organisation to have considered the current commissioning system for drug treatment is the think tank, the Centre for Social Justice whose "Road to Recovery" report in 2019 called for the establishment of a single Recovery and Prevention Agency, addressing all addictions, located within Cabinet Office providing direction to DPHs who in consultation with a Community Advisory Board would prepare a local plan to deliver a National Addition Strategy*. It’s an interesting report - certainly in terms of some of its problematisation.
But in suggesting that a non-clinical agency oversees clinical services and in locating advice and support for DPHs outside any recognisable clinical governance structure, it underestimates the importance in terms of our overall approach to drug-related harms, of clinical interventions. Indeed, while identifying job centres as mandatory local stakeholders, it ignores health altogether. It also - perhaps fatally - leaves the commissioning of drug treatment once again outside the commissioning of other services for vulnerable people and identifies addiction as the defining characteristic of people's lives. It’s unlikely to do much to champion the evidence-based harm reduction policies we need to tackle our increase in deaths.
Those who have been around as long as me will recall the battles that ensued when the Cabinet Office based UKUDCU and the Home Office's DPAS battled with DH for control - and perhaps reflect on the truth of the old saw: that those who are unable to learn from history will be doomed to repeat its lessons. But could this idea from the residential and recovery sectors have legs? At the moment it seems to be the only one on the table.
That’s why it is so important we start within the sector having a conversation about this, whatever one’s views of commissioning, dissemination of expertise and the delivery of services. This is not just about the abolition of PHE. It is about the future of drug and alcohol services and the lives of some of the most vulnerable people in our community.
I'd like to thank those who have helped with the checking and preparation of this blog. You know who you are - x